Updated: 4/20/2021

Sexually Transmitted Infections (STIs)

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Overview
  • STD's are one of the most common gynecologic ER presentations
  • All sexually active partners should be screened for STDs
  • Risk factors incude
    • multiple sexual partners
    • unprotected sexual intercourse
    • young age at first intercourse
    • men who have sex with men
  • Common presentations are
    • ulcerations of the vulvovaginal region
    • abnormal vaginal discharge
    • inguinal rashes
    • inguinal lyphadenopathy
    • abdominal pain
  • 25-50% have multiple genital tract infections
Disease Introduction Presentation Evaluation Treatment

Primary syphilis

  • Caused by Treponema pallidum (spirochetes)
  • Appears in 2-10 weeks
  • Painless genital ulceration (chancre)
  • Dark field microscopy, VDRL/RPR (a rapid but nonspecific screening test), and/or a FTA-ABS (specific and diagnostic, the gold standard)
  • Penicillin

Secondary syphilis

  • Appears 1-3 months after primary infection
  • Maculopapular rash on palms and soles, fever, headache, and generalized lyphadenopathy
  • Condylomata lata (moist lesions on the genitals which are highly infectious)



 

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Tertiary syphilis

  • Aortic aneurysm and aortic regurgitation 
  • Granulomatous gummas of the CNS, heart and great vessels



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Gonorrhea
  • Caused by Neisseriae gonorrhoeae
  • Dysuria, urinary frequency, and purulent yellow-green discharge
  • May progress to PID, high rate of coinfection with with chlamydia
  • Can cause proctitis in the setting of anal intercourse   
      
  • Evaluation should include cervical and urethral cultures for chlamydia and gonorrhea
  • Clean catch urine culture to rule out UTI
  • Saline/KOH/Gram stain of vaginal discharge


  • Ceftriaxone, also treat for presumed chlamydia infection
  • If urethritis is refractory to azithromycin, consider Trichomonas and treat with metronidazole 
Chlamydia 
  •  Caused by Chlamydia trachomatis serotypes D-K
  • Often asymptomatic, but may cause dysuria, cervicitis, PID, lymphogranuloma venereum, or infertility
  • Chlamydia antigen test
  • Tetracycline/doxycycline, azithromycin for cervicitis
  • Use erythromycin base or amoxicillin in pregnancy 
  • Do not need to routinely treat for presumed gonorrhea innection, but should in patients with confirmed gonorrhea or high risk patients
Venereal warts (condylomata acuminata)
  • External lesions associated with HPV 6,11, endocervical warts caused by HPV 16, 18, 31, 33. Transmitted sexually and have a incubation period of 1 to 6 months
  • Painless, soft, fleshy, "cauliflower like lesion"
  • Lesion can be on the vulva, vaginal wall, the cervix, and the perineum


  • Biopsy lesion with 5% acetic acid to detect condylomata acuminata
  • No treatment is satisfactory. Relapse is frequent and requires retreatment
  • Treatment modalities include podofilox (an antimiotic), cryotherapy, laser surgery, or electrocauterizations, and biopsy, imiquimod (interferon inducer) are widely used but require multiple applications and frequently fail
  • Presence during pregnancy does not require cesarian section 
Herpes
  • Caused by HSV-2
  • Parasthesias and burning followed by painful vesicles and ulcerations
  • In primary infections patients may present with fever, malaise, and adenopathy
  • Tzanck smear for lesions suspicious of HSV
  • Topical acyclovir ointment during flare-up, oral acyclovir to decrease rate and severity of recurrence

 

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Questions (1)

(M2.ID.12.4) A 21-year-old man presents to the emergency room complaining of pain upon urination and a watery discharge from his penis. It started a few days ago and has been getting progressively worse. His temperature is 98.0°F (36.7°C), blood pressure is 122/74 mmHg, pulse is 83/min, respirations are 14/min, and oxygen saturation is 98% on room air. Physical exam is notable for a tender urethra with a discharge. Gram stain of the discharge is negative for bacteria but shows many neutrophils. Which of the following is the most likely infectious etiology of this patient's symptoms?

QID: 102806
1

Chlamydia trachomatis

21%

(3/14)

2

Escherichia coli

7%

(1/14)

3

Neisseria gonorrhoeae

71%

(10/14)

4

Staphylococcus saprophyticus

0%

(0/14)

5

Trichomonas vaginalis

0%

(0/14)

M 6 E

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